Hippocrates, Michael Jackson, and medical ethics

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It may be true that we have something to learn from the recent deaths
of Michael Jackson and Heath Ledger. Though for many doctors, such extreme
examples perhaps seem far from the realms of our own practice.

Although traditional medical education includes a smattering of
vignettes and perhaps an OSCE station where we are faced with the
"difficult patient"; as doctors we are left on the whole, to negotiate the
power differential and ability to establish appropriate boundaries, on our
own. Somewhere in this tangle, the feelings elicited by the “powerful” and
the “difficult” must be waived aside to maintain ‘professionalism’ and
focus entirely on the clinical scenario at hand. We fear too much
attention to feelings may negatively affect our practice. But is it really
helpful to deny that our patients make us feel a certain way -
intimidated, angry, joyous, sad, inept?

For the psychiatrist, the power gradient and feelings elicited from
any patient interaction yields invaluable material. This not only gives
huge insight into all the different aspects of the patient’s presentation,
but also allows the doctor to identify and understand why they are being
made to feel a certain way (which is in itself a reflection of the
patient’s own inner world). Put more simply, what we call the transference
and the countertransference – the basic processes in all human
communication.

Psychiatrists and psychologists recognise that part of the doctor –
patient relationship can be reframed as a reflection of the patient’s past
relationships. We would suggest that if a patient treats their doctor in a
dominating, angry or difficult manner, they have treated others in that
way before. Equally, the other part of this relationship is taken up with
the doctor’s response, which is itself coloured by his or her own past
experiences. For example, an angry bed-bound patient accuses you of being
a worthless or useless doctor. It is possible that they may be projecting
their own feelings of uselessness or worthlessness onto you, the
unsuspecting doctor. The psychiatrist should be well rehearsed in thinking
through what may be experienced by the patient at an unconscious level and
put their own feelings in context. The dangers of not taking the time to
do so range from hostile confrontation, making hasty unsafe decisions or
identifying with all one is accused of and seeing oneself as a failure.

Yet this is not solely the stuff of mental health professionals, nor
is it only an issue when dealing with celebrity patients but an integral
part of the everyday workings of a doctor. We suggest that some degree of
training in understanding our emotional reactions to patients would
benefit doctors across all specialties both personally and professionally.

In 1765 Maria Teresa of Austria wrote a letter to her son Pietro
Leopoldo, who had become Grand-Duke of Tuscany, giving him detailed advice
about the proper behaviour of a sovereign in medical matters. The
relationship between the physician and his patient (the sovereign) had to
be strictly protected by the professional secret, which became a State
secret. For this reason, she suggested him to publish every day a
bulletin, regarding the health of the Royal Family, in order to dissolve
every doubt which could have had political consequences. From this point
of view, diplomacy and prudence were even more significant than in the
"normal" professional activity. The hippocratic oath underlined the
importance of the secret: every information gained during work had to be
considered sacred and the greek expression, "àrreta", emphasized this
religious necessity.